January 31, 2019

Background Information: The successful placement of an endotracheal tube (ETT) is a necessary skill all emergency physicians must possess. Performing life-saving interventions are understandably stressful as their failure can lead to morbid consequences and expedited patient death.1,2 The intensive training of emergency physicians, the availability of multiple alternative airway adjuncts and the use of rapid-sequence intubation has helped reduce the intubation complication rate among trauma and medical patients.3-5 Confirmatory methods to ensure the placement of the endotracheal tube are ever changing with no single method being infallible.6. Physical exam findings such as auscultation of the chest and epigastrium, visualization of thoracic movement and fogging of the ETT are not sufficiently reliable to confirm placement.7,8 The use of end-tidal CO2 detection has been shown to have a cumulative false-positive and false-negative failure rate of 10% in accurately confirming the ETT’s location according to the authors of this paper (The paper referenced is a bit dated)­.6 Furthermore, the usage of these devices may contribute to the complications as they frequently require up to 5 ventilations to obtain an accurate reading.9-11 This puts the patient at risk for aspiration especially if the tube is in the esophagus. No.12 Despite a post-intubation CXR taking time, exposing the patient to more radiation and adding to the cost of treatment, it still continues to remain the standard of care.12-14  The authors of this study wished to better understand the test characteristics of utilizing ultrasound to confirm ETT placement. They conducted a systematic review and meta-analysis to quantify the accuracy of this ETT confirmatory method.

November 15, 2018

Background: Cricoid pressure is dead, right? Many have made this claim including a brilliant argument against its use by John Hinds here. Despite the many eulogies, we continue to hear about cricoid pressure so it makes sense that we dive in to the background prior to addressing the recent JAMA Surgery publication.

Cricoid pressure was first described by Dr. Sellick in the 1960’s though similar techniques were described as far back as the 1770s (Sellick 1961). The Sellick’s maneuver entailed the application of pressure over the cricoid cartilage with the thumb and 1-2 additional fingers.  The goal was to compress the cricoid cartilage against the esophagus in order to occlude the esophagus and prevent regurgitation of stomach contents into the upper airway. Initial studies on the maneuver suffered from a bevy of methodological flaws including small n, lack of blinding or randomization and selection bias. Despite this, Sellick’s maneuver was widely adopted and taught to hordes of anesthesia, critical care and emergency residents.

Studies investigating cricoid pressure in the last decade have demonstrated a number of issues with claims that it can prevent passive regurgitation. Check out this free chapter on EMRAP for an in depth discussion. Dynamic MRI studies demonstrate that application of pressure to the cricoid cartilage displaces the esophagus laterally instead of occluding it (Smith 2003, Boet 2012). An ultrasound study demonstrated similar findings: in 60% of patients the esophagus was lateral to the airway and cricoid pressure led to displacement rather than occlusion in all patients. (Tsung 2012).

Additionally, application of cricoid pressure decreases airway patency and increases the chance that your view of the airway will be obscured. (Allman 1995, Palmer 2000, Smith 2002, Oh 2013). Finally, no study to date has demonstrated a reduction in aspiration episodes with the application of cricoid pressure. A large observational study of pregnant patients undergoing C-sections found no difference in aspiration events and that the overall aspiration event rate was low (Fenton 2009). However, up until this point, there has not been a high-quality, randomized controlled trial performed.

October 24, 2018

Background: Establishing IV access has become the norm for patients presenting to the ED.  However with increasing patient volumes, difficulty and delays in acquiring IV access, it seems that anything that could expedite care, reduce pain and suffering, and improve patient care would be welcomed in the ED.  There are several tricks I have learned along the way to achieve just this: No IV access, no problem…performing procedures like a boss…

June 25, 2018

Background: Emergency intubation in the ED is a potentially life-saving procedure in critically ill patients, but does have risks associated with it as we have discussed before on this blog. The authors of the study we are going to review today described a first-attempt intubation success (FPS) rate in the ED to be 85%, despite new technologies such as video laryngoscopy [2]. Successful endotracheal intubation on the initial attempt is vital as it reduces the likelihood of adverse events. Use of the bougie as the primary intubation approach may increase FPS but it is typically reserved as a rescue device only after failed intubation attempts. This is the first randomized controlled trial comparing the bougie vs endotracheal tube + stylet (ETT + stylet) in ED patients with at least 1 characteristic predictive of difficult intubation.  The trial is titled the Bougie use in Emergency Airway Management (BEAM) trial.

June 11, 2018

In terms of airway management, cricothyrotomy is one of the most advanced airway procedures an ED physician will perform.  It is a last resort procedure when a patient is not able to be ventilated/oxygenated and/or intubated.  Typically, this procedure requires the identification of certain landmarks such as the cricothyroid membrane, but what if you can’t identify any landmarks?  What do you do?  We got Rob Bryant on the show to discuss some aspects of a recent nightmare airway case he had. 
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